PPS Rate

Where an FQHC provides an allowable healthcare service at the originating or distant site, the FQHC shall be reimbursed the applicable rate (PPS, APM or FFS).  If an FQHC is both the originating and distant site, and both sites render the same healthcare service, only the distant site will be reimbursed.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.24, 25, 26 & 27. (Accessed Aug. 2025).

In accordance with the District’s Prospective Payment System (PPS) or Alternative Payment Methodology (APM) for FQHCs, the following reimbursement parameters will be established for the purposes of telemedicine in the District:

• Originating Site: An FQHC provider must deliver an FQHC-eligible service to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site.
• Distant Site: An FQHC provider must deliver an FQHC-eligible service to be reimbursed the appropriate PPS, APM, or FFS rate; and
• Originating and Distant Site: In instances where the originating site is an FQHC, the distance site is an FQHC, and both sites deliver a service eligible for the same FQHC visit/encounter all-inclusive PPS or APM code, only the distance site will be eligible to be reimbursed for the appropriate PPS rate for an FQHC-eligible service.

SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5., Physicians Billing Manual. DC Medicaid.  (Jul. 2025) Sec. 15.5. P. 54, Clinic Billing Manual, DC Medicaid (Jul. 2025), Sec. 15.5, P. 51., FQHC Billing Manual, DC Medicaid 15.5, P. 52. (Jul. 2025), Behavioral Health Billing Manual (Jul. 2025) 14.5, p. 70. Inpatient Hospital Billing Guide, 11.5, p. 62 (Jul. 2025), Long-Term Care Billing Manual, 15.5, p. 52 (Jul. 2025). (Accessed Aug. 2025).

D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.

If an FQHC does not elect the APM, it will be paid the PPS for every encounter, regardless of the type of encounter. New FQHC providers will be reimbursed at the PPS rate. The FQHC will receive a separate encounter rate for each type of FQHC service offered: primary care, behavioral health, preventive/diagnostic dental and comprehensive dental.

SOURCE: FQHC Billing Manual, DC Medicaid 17.1, P. 66. (Jul. 2025). (Accessed Aug. 2025).